Purpose To compare clinical and magnetic resonance imaging results of patients who underwent superior capsule reconstruction with a 3 mm (Group 1) versus 6 mm (Group 2) human dermal allograft. Methods Between September 2014 and February 2022, patients who underwent superior capsule reconstruction at a single institution, with a minimum of 1‐year follow‐up, were included. Preoperative age, sex, and Hamada grade were recorded. Pre‐ and postoperative acromiohumeral distance, American Shoulder and Elbow Surgeons (ASES), Oxford, visual analog scale (VAS) for pain, and postoperative single‐assessment numeric evaluation score were recorded. Postoperative magnetic resonance image was routinely obtained regardless of symptoms. Results There were 39 shoulders in Group 1 and 22 shoulders in Group 2. There was no difference between in preoperative age ( P = .6412), acromiohumeral distance ( P = .7638), ASES ( P = .4612), and Oxford ( P = .55517). There was significant improvement in both groups in ASES, Oxford, and VAS ( P < .0001), but no difference in acromiohumeral distance for Group 1 ( P = .666) or Group 2 ( P = .1188). There was a significant difference between Group 1 and 2 in postoperative ASES (76.6 vs 94, P = .0002), Oxford (41.7 vs 47, P = .0005), VAS (2.2 vs 0.3, P = .0062), and single‐assessment numeric evaluation (75 vs 92.3, P = .0002). Group 2 had a lower graft tear rate (27.3% vs 64.1%, P = .0057). Group 2 also had a significantly lower lateral‐sided graft failure (0% vs 40%, P = .0099). In Group 1, 87% met minimal clinically important difference for ASES, 77% for Oxford, and 90% for VAS. In addition, 67% met substantial clinical benefit for ASES, 64% for Oxford, and 72% for VAS. In Group 2, 100% met minimal clinically important difference for ASES, Oxford, and VAS and 100% met SCB. Conclusions Patients who undergo superior capsule reconstruction with a 6 mm human dermal allograft have significantly lower lateral‐sided graft tears, leading to better functional outcomes compared with those with 3 mm grafts. Level of Evidence Level III, retrospective comparative study.

Background: Studies to date of superior capsular reconstruction (SCR) comparing outcomes of healed grafts versus torn grafts do not separate graft tears based on location of the tear, rather they combine and report all tears as a single group. Purpose/Hypothesis: The purpose of this study was to correlate functional outcome with graft integrity and graft tear location after SCR with a dermal allograft. It was hypothesized that the functional outcomes of patients with an intact graft would be equivalent to those with graft tears leaving the tuberosity covered. Study Design: Cohort study; Level of evidence, 3. Methods: Patients who underwent SCR with an acellular dermal allograft at a single institution were included. Pre- and postoperative American Shoulder and Elbow Surgeons (ASES), Oxford Shoulder Score, visual analog scale (VAS) for pain, and postoperative Single Assessment Numeric Evaluation (SANE) scores were recorded. A magnetic resonance imaging scan was performed postoperatively to assess graft integrity. Results: A total of 39 patients met inclusion criteria. Mean age of patients was 60.4 8.7 years; mean follow-up was 53.3 +/- 25 months (range, 14-98 months). Magnetic resonance imaging performed at a mean of 17.5 months (range, 6-66 months) demonstrated an intact graft in 14 (36%); tear from the glenoid in 11 (28%), from midsubstance in 4 (10%), and from the tuberosity in 8 (21%); and complete graft absence in 2 (5%). Patients were divided into group 1 (intact graft), group 2 (tuberosity covered: tears from glenoid and midsubstance tears), and group 3 (tuberosity bare: tears from the tuberosity and dissolved or absent grafts). In group 1, there was significant improvement in ASES (37.9 to 88.5; P < .001), Oxford (25.2 to 46.2; P < .001), and VAS (6.8 to 0.9; P < .001). In group 2, there was significant improvement in ASES (32.2 to 86.1; P < .001), Oxford (23.4 to 44.2; P < .001), and VAS (7.3 to 1.3; P < .001). In group 3, there was no significant improvement in ASES (40.3 to 45.8; P = .50) or Oxford (33.5 to 31.4; P = .81), but there was a significant reduction in VAS (7.1 to 5.4; P = .03). There was no significant difference between group 1 and 2 in postoperative ASES (88.5 vs 86.1; P = .59), Oxford (46.2 vs 44.2; P = .07), VAS (0.9 vs 1.3, P = .42) and SANE (85.4 vs 83.2; P = .92) scores. However, group 3 had significantly lower ASES (45.8; P < .001), lower Oxford (31.4; P < .001), lower SANE (45.4; P < .001), and higher VAS (5.4; P < .001) scores than groups 1 and 2. There were no differences in outcomes based on sex (P = .72), previous surgery (P = .06), preoperative acromiohumeral distance (P = .57), and preoperative Goutallier stage of the supraspinatus (P = .16). Conclusion: Patients who underwent SCR with a dermal allograft and developed a graft tear leaving the tuberosity covered had equivalent functional outcomes to those with an intact graft.

Background: Radial head arthroplasty (RHA) is commonly used for the treatment of comminuted radial head fractures. Indications as well as implant types continue to evolve. RHA has had good outcomes with midterm longevity. The literature is limited to small case series with varying implant types, and larger studies are needed to determine the optimal implant type and radial head diameter. Methods: A retrospective analysis of RHA cases performed by 75 surgeons at 14 medical centers in an integrated health care system between 2006 and 2017 was completed. Patient demographics, comorbidities, implant type and head diameter, and indications for revi-sion were recorded. Patients' in-person clinical visit data were recorded. Patients were also contacted via telephone at a minimum of 2 years to obtain abbreviated Disabilities of the Arm, Shoulder, and Hand questionnaire and Oxford scores. Implant survivorship was also captured within our integrated system.Results: 405 cases met our inclusion criteria. Mean age was 51.5 +/- 15.5 years (range 16-88 years) and more common in females (62%). Chart review and telephone follow-up was performed at a mean of 68.9 +/- 31.5 months (range 24-146 months). Our study found that revision rate was positively correlated with increasing radial head diameter. A 26-mm head had 7.7 odds of revision compared to a size 18-mm head (95% con-fidence interval 1.2-150.1). More than 95% of revision cases were performed within the first 36 months of the index procedure. Obese patients had a significantly lower mean postoperative Oxford score (35.5) compared to controls (38.3) (P = .02). There was a significantly higher overall reoperation rate for terrible triad (18.4%) vs. isolated injuries (10.4%) (P =.04). There was no difference between Acumed Anatomic and Evolve radial head implants in overall reoperation, implant revision, postoperative range of motion, or patient-reported outcomes.Conclusions: Risk of revision is directly correlated with implanted radial head diameter. There were no differences in outcomes and com-plications between the 2 main implants used. Individuals who did not undergo a revision by 3 years' time tend to retain the implant. Terrible triad injuries had a higher all-cause reoperation rate than isolated radial head fractures, but no difference in the rate of RHA revision. These data reinforce the practice of downsizing radial head implant diameter.Level of evidence: Level IV; Case Series; Treatment Study (c) 2022 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

P¼0.70). OSPBT performed with one SSSA (21.70 mm) demonstrated significantly greater migration than ASPBT with IS (4.31mm, P<0.001) and OSPBT with IS (5.04 mm, P<0.001).Three patients (9.4%) who had OSPBT with one SSSA and one who had ASPBT with two SSSAs (3.8%), developed a Popeye deformity; none occurred in the IS groups.Mean 12-week bead migration in patients with versus without Popeye deformity was 60.8 mm and 11.2 mm, respectively (P<0.0001).PROMs did not differ at final follow-up.Conclusion: ASPBT and OSPBT with IS fixation demonstrated the least tendon migration, while OSPBT with one SSSA yielded the most.Compared to IS, fixation with one, but not two, SSSAs resulted in significantly greater migration.Average bead migration following a Popeye deformity was 6.1cm.To minimize migration when using SSSAs, at least 2 sutures should be used with an interlocking pattern within the tendon.

P¼0.70). OSPBT performed with one SSSA (21.70 mm) demonstrated significantly greater migration than ASPBT with IS (4.31mm, P<0.001) and OSPBT with IS (5.04 mm, P<0.001).Three patients (9.4%) who had OSPBT with one SSSA and one who had ASPBT with two SSSAs (3.8%), developed a Popeye deformity; none occurred in the IS groups.Mean 12-week bead migration in patients with versus without Popeye deformity was 60.8 mm and 11.2 mm, respectively (P<0.0001).PROMs did not differ at final follow-up.Conclusion: ASPBT and OSPBT with IS fixation demonstrated the least tendon migration, while OSPBT with one SSSA yielded the most.Compared to IS, fixation with one, but not two, SSSAs resulted in significantly greater migration.Average bead migration following a Popeye deformity was 6.1cm.To minimize migration when using SSSAs, at least 2 sutures should be used with an interlocking pattern within the tendon.

OBJECTIVE:Superior capsule reconstruction (SCR) is a treatment option for irreparable massive rotator cuff tears (MRCT). The purpose of this study is to describe a classification system for graft integrity and tear location. METHODS:Patients who underwent SCR at a single institution were included. Pre-operative age, gender, prior surgery, Hamada grade, and Goutallier stage were recorded. An MRI was performed postoperatively to assess graft integrity and tear location. RESULTS:53 patients met inclusion criteria. Mean age was 60.1 ± 7.9 years. A post-operative MRI was performed in 42 (80%) patients at a mean of 14 ± 7 months (range, 6-40 months). MRIs demonstrated an intact graft in 16 (38%) shoulders. Of the 26 graft tears, 14 (54%) were from the glenoid, 5 (19%) mid-substance, 6 (23%) from the tuberosity, and 1 (3.8%) had complete graft absence. CONCLUSION:Graft tears are common following SCR. We describe four different graft tear locations and submit a classification system that can be used in future studies to better compare outcomes based on graft integrity and tear location. Clinical correlation with graft integrity and graft tear location needs to be further investigated.

Ulnar collateral ligament reconstruction of the elbow has evolved substantially since its introduction in 1974. Numerous variations of the surgery have been introduced, including modifications in tunnel creation, graft tensioning, and fixation. These changes have aimed to improve overall quality of the reconstruction; however, even the most commonly used techniques still present many challenges. We describe a technique for ulnar collateral ligament (UCL) reconstruction using bisuspensory button fixation and a single tunnel on both the ulnar and humeral sides. This technique avoids many of the most common complications and methods of failure of UCL reconstruction, provides immediate strong graft fixation, and offers the surgeon a technically less demanding procedure.

Purpose: The purpose of this study was to report the complications of elbow arthroscopy in a large community practice with multiple surgeons and to analyze potential risk factors for these complications. Methods: Patient demographic information, surgical variables, surgeon variables, and complications were retrospectively reviewed for all elbow arthroscopies performed within the health network from 2006 to 2014. Inclusion criteria included patients of any age undergoing a primary and revision elbow arthroscopy, which may have been performed in conjunction with other procedures. Exclusion criteria included incorrectly coded procedures where arthroscopy was not performed and no postoperative follow-up. Statistical calculations were performed using a binary logistic regression analysis to fit a logistic regression model. Results: 560 consecutive elbow arthroscopies in 528 patients performed between 2006 and 2014, by 42 surgeons at 14 facilities, were reviewed. 113 procedures were performed in pediatric patients under the age of 18. The average age was 38.6 years (range: 5-88). There were 444 males. The average length of follow-up was 375.8 days (2 to 2,739 days). Overall, heterotopic ossification occurred in 14 of 560 cases (2.5%) (all males), and 20 of 560 (3.5%) cases developed transient nerve palsies (8 ulnar, 8 radial, 1 median, 3 medial antebrachial cutaneous). There were 3 (0.5%) deep and 11 (2%) superficial infections. There were no vascular injuries, compartment syndrome, deep vein thrombosis, or pulmonary embolism. Elevated blood sugar was a significantly higher risk for infection (odds ratio [OR] 4.11, 95% confidence interval [CI] 1.337 to 12.645; P=.0136). Previous elbow surgery (OR 3.57, 95% CI 1.440 to 8.938; P=.006) and female sex (OR 4.05; 95% CI 1.642 to 9.970; P=.002) had a significantly higher risk for nerve injury. Relative to pediatric patients, there were higher odds in adults for nerve injury, infection, and heterotopic ossification, but none reached significance. Conclusions: Elbow arthroscopy is a safe procedure with low complication rates. Diabetes is a risk factor for infection. Prior surgery and female sex are risk factors for nerve injury. Level of Evidence: Case series, level 4

Background: Ulnar collateral ligament reconstruction (UCLR) has allowed the return of overhead athletes to throwing sports. We describe a new double suspensory (DS) technique using a single tunnel in the ulna and humerus, achieving fixation with adjustable loop buttons. Methods: Inclusion criteria included skeletally mature baseball players with clinical and magnetic resonance imaging diagnosis of UCL insufficiency who failed a trial of structured nonoperative treatment. A total of 36 baseball players underwent DS UCLR, between 2011 and 2017, by 1 surgeon with minimum 2-year follow-up. The graft was fixated with an adjustable button loop on the humeral side and a tension slide technique with a button on the ulnar side. Pre- and postoperative Kerlan-Jobe Orthopaedic Clinic and Single Assessment Numerical Evaluation and postoperative Conway scores were obtained. Results: The mean age was 19.8 +/- 4.6 years (range, 14-35 years). All were male. Mean years played before surgery was 14.3 +/- 4.6 years (range, 8-28 years). There were 32 (89%) pitchers and 4 (11%) position players. There were 13 (36%) high school, 20 (55%) college, 2 (6%) minor league, and 1 (3%) adult league athletes. The mean follow-up was 55.3 +/- 23.7 months (range, 26-97 months). There was significant improvement in Kerlan-Jobe Orthopaedic Clinic (33.2 +/- 19.9 to 89.7 +/- 15.1, P < .0001) and Single Assessment Numerical Evaluation (20.7 +/- 16.7 to 93.6 +/- 11.9, P < .0001) scores. Using Conway scoring, 25 (69%) had excellent, 5 (14%) good, 3 (8%) fair, and 3 (8%) poor scores. Mean return to play was 9 +/- 1.5 months (range, 6-16 months). Only 1 (3%) athlete required a revision surgery and ultimately returned to play and 1 (3%) hardware removal. None developed ulnar nerve symptoms. Conclusion: DS fixation for UCLR in baseball players can lead to excellent clinical results and early return to play. (C) 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Background: The purpose of our study was to compare the acromiohumeral distance (AHD) between radiographic and magnetic resonance images (MRIs) of the same shoulder with massive rotator cuff tears (MRCTs). Methods: Thirty-four shoulders with MRCTs that had an MRI and radiograph of the same shoulder within an average of 40.3 days (range: 8-109 days) were identified. AHD was measured digitally on radiograph and MRI by 3 examiners. Shoulders were grouped into Hamada grades <3 (group 1) and Hamada grades >= 3 (group 2). Results: The mean age was 66.4 years (range: 51-89). There were 19 men (59%). The Kappa for interrater reliability was 0.982 (95% confidence interval [CI] 0.975. 0.988) for radiographs and 0.88 (95% CI 0.75, 0.94) for MRI. There was a significant difference in the mean AHD of group 1 on radiograph vs. MRI (7.9 mm vs. 2.5 mm, respectively; P < .0001), but no difference in group 2 (1.8 mm vs. 2.2 mm, respectively; P =.45). There was no difference in AHD in group 1 between shoulders with Goutallier stage <3 (8.1 +/- 1.9 mm) and those with Goutallier stage >= 3 (7.3 +/- 2.1 mm) (P =.3479). There was no difference in AHD in group 2 between shoulders with Goutallier stage <3 (3.0 +/- 0.1 mm) and those with Goutallier stage >= 3 (1.5 +/- 1.0 mm) (P =.079). Conclusion: There is a significant difference in AHD measurements between radiograph and MRI of the same shoulder with MRCT in early Ramada grades. AHDs measured on radiograph and MRI should not be used interchangeably in early Hamada grades to assess outcomes of superior capsule reconstruction and similar procedures. (C) 2019 Journal of Shoulder and Elbow Surgery Board of Trustees. All rights reserved.

Objectives: Superior capsular reconstruction (SCR) is an emerging treatment option for irreparable massive rotator cuff tears (MRCT). The initial description utilized fascia lata autograft, but acellular dermal matrix (ADM) has become the graft of choice in the United States. Several reports have demonstrated excellent short-term functional improvement and patient satisfaction, but there is limited data correlating imaging studies of graft integrity to functional outcome. The purpose of this study was to determine if functional outcome after SCR is dependent on dermal allograft integrity on post-operative MRI. Methods: Inclusion criteria were patients who underwent an SCR by one of 5 fellowship-trained surgeons at a single institution for the indication of pain attributable to irreparable MRCT that failed non-operative treatment. Exclusion criteria included arthritis, prior infection, revision SCR, and less than 6 months follow-up. Pre- operative data including age, gender, prior surgery, Hamada grade, and Goutallier stage were recorded. Intra-operative data including surgical findings and concomitant procedures were recorded. Pre- and post-operative acromiohumeral distance (AHD), American Shoulder and Elbow Surgeons (ASES), Oxford, visual analogue scale (VAS) and post-operative SANE score were recorded. In 90% of cases, a 3 mm ADM was used and in 10% of cases, a 6 mm ADM was used (doubled over 3 mm graft). All grafts were fixed by a double-row, trans-osseous equivalent technique on the tuberosity and with a mean of 3 anchors on the glenoid. Patients were routinely offered to undergo an MRI postoperatively regardless of symptoms. Results: 53 patients met our inclusion criteria. Mean age was 60.1+7.9 years (range 34 to 77). 68% were male; 34% had at least one prior procedure; 58% had a concomitant procedure; 57% were Hamada 1, 38% Hamada 2, and 5% Hamada 3. Pre-op Goutallier stage was 3.7% grade 0, 17% grade 1, 40% grade 2; 26% grade 3; 13% grade 4. The mean clinical follow-up was 15+7.8 months (range 6-42 months). 81% of patients underwent an MRI post-operatively. The mean time for MRI was 14+7 months (range 6 -40). MRI revealed that 38% had a completely intact graft, 33% had a tear from the glenoid, 12% had a mid-substance tear, 14% tear from the tuberosity, and 2% had complete graft absence. There was a significant improvement in ASES (37.7 to 79.5, P<0.0001), Oxford (26.3 to 44, P<0.0001), and VAS (7 vs 2.3, P<0.0001). There was no difference between pre-op and post-op AHD (7.3 mm vs 6.9mm, P=0.57). There was no association between pre-operative AHD (P=0.9), Goutallier stage (P=0.43), Hamada grade (P=0.49) with post-operative ASES scores. There was a significant correlation between graft integrity with final outcome. There was no difference in post-operative ASES score when the graft was completely intact or torn from the glenoid (P=0.39), but graft tear from the tuberosity resulted in a significantly lower ASES score (P=0.013). Conclusions: In patients who undergo SCR for MRCT, there is significant improvement in ASES, Oxford, and VAS. This improvement is seen in patients who have an intact graft, as well as those where the graft is torn from the glenoid, but not those torn from the tuberosity. This supports the concept of the graft functioning as a ”biologic tuberoplasy” preventing bone-to-bone contact between the tuberosity and acromion. Preoperative AHD, Goutallier, Hamada, gender, or age did not have an association with post-operative ASES scores.

Background: Acellular dermal matrices (ADMs) have been used in the treatment of shoulders with massive rotator cuff tears (MRCTs). Despite clinical improvement, correlation of clinical findings with ADM integrity on imaging has not been investigated. Hypothesis: The pain in shoulders with MRCTs is partially due to bone-to-bone contact between the tuberosity and acromion. Coverage of the tuberosity with an intact graft or a graft that is torn in a way that the tuberosity remains covered will act as an interpositional tissue, preventing bone-to-bone contact and leading to clinical improvement. Study Design: Case series; Level of evidence, 4. Methods: Between 2006 and 2016, a total of 25 shoulders with MRCTs underwent a procedure with an ADM. Pre- and postoperative visual analog scale (VAS) results, American Shoulder and Elbow Surgeons (ASES) score, Hamada grade, and Goutallier classification were reviewed. A postoperative magnetic resonance imaging (MRI) was obtained in 22 (88%) shoulders. The status of the graft was divided into the following categories: type I, intact graft; type II, graft tear with tuberosity covered; and type III, graft tear with tuberosity uncovered (bare). Results: The mean patient age was 61 years (range, 49-73 years), and the mean follow-up was 25.6 months (range, 10-80 months). Mean length from surgery to postoperative MRI was 13.9 months (range, 6-80 months). The graft was torn in 59% (13/22 shoulders). Significant improvements were found in VAS and ASES scores (7 vs 0.7 and 32.6 vs 91.2, respectively; P < .01) for type I grafts and in VAS and ASES scores (8.1 vs 1.3 and 26.3 vs 84.6, respectively; P < .01) for type II grafts. No difference was found in postoperative VAS and ASES (0.7 vs 1.3 and 91.2 vs 84.6, respectively; P = .8) between type I and type II grafts. No improvement was seen in VAS (7.3 vs 5.7; P = .2) or ASES (30.6 vs 37.2; P = .5) for type III grafts. Conclusion: MRI appearance of the graft has a significant impact on functional outcomes. Patients with an intact graft or a graft tear leaving the tuberosity covered have lower pain and higher functional scores than those in whom the torn graft leaves the tuberosity uncovered.

Background: Use of heterotopic ossification (HO) prophylaxis remains controversial following a distal biceps repair.

BACKGROUND:The goal of this study was to evaluate current physician ratings websites (PRWs) to determine which factors correlated to higher physician scores and evaluate physician perspective of PRWs.METHODS:This study evaluated two popular websites, Healthgrades.com and Vitals.com, to gather information on practicing physician members of the American Shoulder and Elbow Society database. A survey was conducted of the American Shoulder and Elbow Society (ASES) membership to gather data on the perception held by individual physicians regarding PRWs.RESULTS:We found that patients were more likely to give physicians positive reviews and the average overall score was 8.35 (3.75-10). Patient wait time (P=0.052) trended toward significance as a major factor in determining the overall scores, while ratings in both physician bedside manner (P=0.001) and physician/staff courtesy (P=0.002) were significant in reflecting the overall score given to the physician. According to our survey, a majority of the respondents were indifferent to highly unfavorable to PRWs (88%) and the validity of their ratings (78%).CONCLUSION:As PRWs become increasingly popular amongst patients in this digital age, it is critical to understand that the scores are not reflective of a significant proportion of the physicians' patient population. Physicians can use this study to determine what affects a patient's experience and focus efforts on improving patients' perception of quality, overall satisfaction, and overall care. Consumers may use this study to increase their awareness of the potential for significant sampling error inherent in PRWs when making decisions about their care.

Background: Distal triceps tendon ruptures are rare. The authors present a series of 184 surgically treated, acute, traumatic triceps tendon avulsions and compare the complications between those treated with anchors (A) versus transosseous (TO) suture repair. Hypothesis: No difference exists in the retear rate between TO and A repairs. Study Designed: Cohort study; Level of evidence, 3. Methods: All patients who underwent an open primary repair of a traumatic triceps tendon avulsion within 90 days of injury, between 2007 and 2015, were retrospectively reviewed. Surgeries were performed within a multisurgeon (75 surgeons), multicenter (14 centers), community-based integrated health care system. Patient demographic information, type of repair, complications, and time from surgery to release from medical care were recorded. Results: 184 triceps tears in 181 patients met the inclusion criteria. The mean age was 49 years (range, 15-83 years). There were 169 males. The most common mechanisms of injury were fall (56.5%) and weight lifting (19%). Mean time from injury to surgery was 19 days (range, 1-90 days); in 74.5% of cases, surgery was performed in 3 weeks or less. There were 105 TO and 73 A repairs. No significant difference was found between the two groups in the mean age (P = .18), sex (P = .51), completeness of tears (P = .74), tourniquet time (P = .455), and prevalence of smokers (P = .64). Significant differences were noted between TO and A repairs in terms of reruptures (6.7% vs 0%, respectively; P = .0244), overall reoperation rate (9.5% vs 1.4%; P = .026), and release from medical care (4.3 vs 3.4 months; P = .0014), but no difference was seen in infection rate (3.8% vs 0%; P = .092). No difference was noted in release from medical care in patients who underwent surgery 3 weeks or less after injury compared with those undergoing surgery more than 3 weeks after injury (3.90 vs 4.09 months, respectively; P = .911). Conclusion: Primary repair of triceps ruptures with TO fixation has a significantly higher rerupture rate, higher reoperation rate, and longer release from medical care than does repair with A fixation. Implementation of suture anchors in triceps repairs offers a lower complication rate and earlier release from medical care.

Introduction: Acromiohumeral distance (AHD) measures superior migration of humeral head (SMH) in shoulders with massive rotator cuff tears (MRCT) and is used as an indication for reconstructive procedures such as tendon transfers, superior capsular reconstruction, and reverse shoulder arthroplasty. The exact cause of SMH and progression of Hamada grades is not known. We compared AHD between X-ray (obtained upright) and MRI (performed supine) of the same shoulder and correlated it with Hamada grade, Goutallier stage, and Critical Shoulder Angle (CSA) to determine if these have a factor on AHD and progression of SMH.

Objectives: Pectoralis major tendon ruptures are relatively uncommon injuries. The literature is limited to several small case series, the largest containing 24 cases, and systematic reviews. However, still little is known about the demographics of this injury or the outcomes of operative repairs. We present a series of 134 traumatic pectoralis major tendon ruptures, which were treated surgically. This study aims to provide more information on injury demographics and surgical outcomes in order to learn more about making the diagnosis, preferred method of repair, and complications surrounding surgical treatment of both acute and chronic tears. Methods: A retrospective review was performed on 134 acute and chronic traumatic pectoralis major tendon ruptures repaired surgically from 2008 to 2014. Procedures were performed at a multi-surgeon (55 surgeons), multi-center (13 centers) community-based integrated health care system. Pre- and post-operative data were obtained by a retrospective chart and imaging review. Categorical variables were compared using chi-square or Fisher’s exact test. Results: 134 pectoralis major tendon ruptures were treated surgically. The average age was 34 years (15 to 61). 18% were laborers and the most common mechanism of injury was weight lifting (62%). The average time from injury to surgery was 10 weeks. 76% were acute, 8% were subacute, and 16% were chronic ruptures. Operative findings revealed a tendon rupture in 92% of cases (122/134), a musculotendinous rupture in 13% (18/134), and 0.7% partial tears (1/134). Surgical repair techniques consisted of suture anchors (40%), sutures through bone tunnels (25%), suture button (19%), and an end-to-end suture repair (8%). Six patients (4%) needed allograft augmentation at the time of surgery. There were 17 complications (13%): 4 infections, 5 cosmetic wound concerns, 1 transient neuropraxia, 2 fractures, 2 postoperative frozen shoulders, and 3 failures. Surgical treatment with bone tunnels was associated with the highest complication rate in this series (5%), followed by suture anchors (4.4%), end-to-end repair (2.2%), and suture button repair (0.74%). One patient had a re operation, which was for a failed repair (0.7%). The average follow up time was 71 days (1-2268 days). 86% of patients were able to return to their occupation at full capacity. The complications rates between each method of repair seen in our study were not statistically different from one another. When “implant” versus “no implant” was evaluated, we found that use of an implant was associated with a lower re-tear rate (p=.0782), a lower rate of fracture (p=.0782), and a lower rate of post operative stiffness (p=0.0782), and all 3 trended toward significance. Conclusion: This is the largest single series regarding the surgical treatment of pectoralis major tendon ruptures. Our study added to what we know about patient demographics and mechanisms of injury for a pectoralis tendon rupture. Surgical repair of pectoralis major tendon ruptures can be performed safely with a low re-rupture rate and low risk of complications. Using a suture button had the lowest complication rate, and the use of an implant may potentially minimize complications. Further prospective studies are needed to determine the best surgical repair technique.

We present the largest long head of the biceps tendon procedure study in the literature, with analysis by tenodesis technique and location.

The surgical repair of distal biceps tendon ruptures has an overall low rate of serious complications, regardless of approach or technique. However, two-incision technique has a higher rate of posterior interosseous nerve palsy, heterotopic bone formation, and re-operation rate.

Background: Distal biceps brachii tendon ruptures lead to substantial deficits in elbow flexion and supination; surgical repair restores muscle strength and endurance. Purpose: To examine clinical and surgical outcomes for distal biceps tendon repairs in a large, multispecialty, integrated health care system. Study Design: Cohort study; Level of evidence, 3. Methods: Retrospective cohort study of distal biceps tendon repairs performed between January 1, 2008, and December 31, 2015. The repair methods were classified as double-incision approach using bone tunnel–suture fixation or anterior single-incision approach. Anterior single incisions were further classified according to the fixation method: cortical button alone, cortical button and interference screw, or suture anchors alone. Patient demographics, surgeon characteristics, range of motion, and complications were analyzed for all repair types. Results: Of the 784 repairs that met the inclusion criteria, 639 (81.5%) were single-incision approaches. When comparing double-incision and single-incision repairs, there was a significantly higher rate of posterior interosseous nerve palsy (3.4% vs 0.8%, P = .010), heterotopic bone formation (7.6% vs 2.7%, P = .004), and reoperation (8.3% vs 2.3%, P < .001). The most common nerve complication encountered was a lateral antebrachial cutaneous nerve palsy (n = 162), which was significantly more common in the single-incision repairs than in the double-incision repairs (24.4% vs 4.1%, P < .001). When excluding lateral antebrachial cutaneous nerve palsies, there was no significant difference in the overall nerve palsies between single-incision and double-incision (5.8% vs 6.9%, P = .612). The overall rate of tendon rerupture was 1.9% (single incision, 1.6%; double incision, 2.8%; P = .327). The overall rate of postoperative wound infection was 1.5% (single incision, 1.3%; double incision, 2.8%; P = .182). The average time from surgery to release from medical care was 14.4 weeks (single incision, 14 weeks; double incision, 16 weeks; P = .286). Patients treated with cortical button plus interference screw were released significantly sooner than were patients with other single-incision repair types (13.1 ± 8.01 weeks, P = .011). There were no significant differences in rates of motor neurapraxia, infection, rerupture, and reoperation with regard to surgeon’s years of practice, fellowship training, or case volume. Conclusion: The surgical repair of distal biceps tendon ruptures has an overall low rate of serious complications, regardless of approach or technique. However, the double-incision technique has a higher rate of posterior interosseous nerve palsy, heterotopic bone formation, and reoperation rate. Surgeon’s years of practice, fellowship training, and case volume do not affect the rate of major complications.